Caspian Journal of

Dental Research

Original Article

Reliability and validity of the persian version of the General Oral Health Assessment Index (GOHAI)

Mina Motallebnejad (DDS)

1, Kataayoun Mottaghi (DDS)2, Shervin Mehdizade (DDS)

3, Farshid

Alaeddini (PhD)4, Ali Bijani (MD)

5

1. Associate Professor, Cellular & Molecular Biology Research Center, Department of Oral Medicine, Faculty of Dentistry, Babol

University of Medical Sciences, Babol-Iran.

2. General Dentist.

3. Assistant Professor, Department of Prosthodontics, Faculty of Dentistry, Babol University of Medical Sciences, Babol-Iran.

4. Scholar, Health Research and Development Institute, Tehran-Iran.

5. General Practitioner, Social Determinants of Health Research Center, Babol University of Medical Sciences, Babol-Iran.

Corresponding Author: Mina Motallebnejad, Faculty of Dentistry, Babol University of Medical Sciences, Babol- Iran.

Email: mmotallebnejad@yahoo.com Tel: +981113230831

Abstract

Introduction: As the oral health related quality of life has been important in many dental patients

GOHAI is an acceptable tool, preparing its Persian version can be useful in oral health research

among Persian populations. The aim of this study was to evaluate the reliability and validity of the

Persian version of General Oral Health Assessment Index (GOHAI).

Methods: Translation was performed using the forward-backward process. The final Persian

version was then tested through an interview and test-retest to evaluate its comprehensibility and

reliability. A sample of 150 subjects (20-65 years old) was requested to answer the GOHAI items

prior to a clinical examination.

Data on the subjects’ socio-demographic characteristics and self-rating report of oral health,

general health and dental care needs were recorded. Internal consistency was calculated by

Cronbach’s α. Interview and test-retest reliability was evaluated by weighted kappa. Concurrent

validity was assessed by comparing GOHAI scores and self-rated measures of oral health, general

health and perceived dental care needs. Discriminant validity was tested by comparing GOHAI

scores with clinical oral condition.

Results: The mean GOHAI score was 46.78±7.85. Cronbach’s α (0.78) showed a high internal

consistency and homogeneity between items. Weighted kappa coefficient for the interview varied

from 0.60 to 0.96 and was between 0.33 and 0.64 for test-retest. Bland-Altman plot displayed a

good agreement between the two GOHAI scores for both the interview and test-retest. There was

no significant relationship between GOHAI scores and self-rating oral health (p=0.090), but there

was a relationship between self-rating general health and mean GOHAI scores (p=0.047). Also,

the low GOHAI scores were associated with the perceived dental care needs (p=0.001). There was

an opposite correlation between GOHAI scores and caries and missing teeth (p<0.0001).

Conclusions: The Persian version of the GOHAI exhibits acceptable reliability and validity, so it

can be used widely throughout the Persian communities.

Keywords: GOHAI, Persian, Quality of life, Questionnaire

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Validation of persian GOHAI version

9

GOHAI)پرسشنامه )پايايي و روايي نسخه فارسي

چكيذه

امزيسٌ کیفیت سوذگی يابستٍ بٍ سالمت دَان در بیماران دوذاوپششکی ي پششکی اَمیت يیژٌ ای داشتٍ :مقذمه

فارسیتًاوذ در جًامع باشذ. لذا تُیٍ وسخٍ فارسی آن می مًرد قبًل می GOHAIي در ایه سمیىٍ پزشسىامٍ

GOHAI َذف ایه مطالعٍ بزرسی ريایی ي پایایی وسخٍ فارسی پزسشىامٍ تفادٌ قزار گیزد.اس مًردسبان

.است

تزجمٍ پزسشىامٍ اوجام شذ. وسخٍ وُایی forward-backward با استفادٌ اس ريش :مواد و روش ها

افزاد وفز 150ارسیابی گزدیذ. test-retest ي پایایی تًسط مصاحبٍ ي comprehensibilityجُت بزرسی

اطالعات مزبًط بٍ مشخصات فزدی .سالٍ قبل اس معایىٍ دَان پزسشىامٍ وُایی را تکمیل کزدوذ 65تا 20

با internal consistency.سالمت دَان خًد ثبت شذ اقتصادی ي وظزات افزاد اس سالمت عمًمی ي

Weighted)با ضزیب کاپا test-retest استفادٌ اس ضزیب آلفا کزيوباخ محاسبٍ گزدیذ. پایایی مصاحبٍ ي

Kappa) تعییه گزدیذ. ريایی Concurrent ٌاس طزیق مقایسٍ ومز GOHAI ي وظزات افزاد اس سالمت

اس طزیق مقایسٍ Discriminant عمًمی ي سالمت دَان ي ویاسَای درماوی دوذاوپششکی محاسبٍ شذ. ريایی

.شذ با يضعیت سالمت دَان )معایىات بالیىی( محاسبٍ GOHAI ومزٌ

دَىذٌ وشان 78/0بًد ضزیب آلفای کزيوباخ معادل GOHAI 87/64± 85/7 میاوگیه ومزٌ يافته ها:

internal consistency ي homogeneity بیه مًارد بًد.

متغیز بًد. 64/0تا 33/0اس test-retest ي بزای 96/0تا 6/0بزای مصاحبٍ اس Weighted ضزیب کاپا

وشان داد ارتباط معىی test-retest در مصاحبٍ GOHAI خًبی بیه ومزٌتًافق Bland-Altmanاما

يلی ارتباط بیه ومزٌ (p =0.090)وظز بیماران اس سالمت دَان يجًد وذاشت ي GOHAI داری بیه ومزٌ

GOHAI ي وظز بیمار وسبت بٍ سالمت عمًمی يجًد داشت(p=0.047 ) َمچىیه ومزات کم GOHAI

ي دوذان َای کشیذٌ GOHAI ارتباط معکًس بیه ومزٌ p)=(0.001وی در ارتباط بًدبا ویاسَای درمان دوذا

>p) (0.0001شذٌ ي پًسیذٌ يجًد داشت

تُیٍ شذٌ ريایی ي پایایی قابل قبًلی داشتٍ ي می تًان اس آن در GOHAIوسخٍ فارسی :نتيجه گيري

.زدجمعیت فارسی سبان جُت بزرسی َای بُذاشتی ي سالمت دَان استفادٌ ک

، فارسی، کیفیت سوذگی، پزسشىامGOHAIٍ :واژگان کليذي

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Introduction

Recently, the definition of (oral) health has shifted

to address more than the absence of physical disease.

The new definition defines health as an individual's

perception of his health in the context of physical,

psychological and social well-being (1).The disease-

based approach is the traditional way to measure oral

health. Oral disease has been assessed by objective and

quantitative indicators (2).

Oral disease prevalence has been studied in

different samples of adults, but less is known about

how the disease and symptoms affect adults' daily

activities and quality of life (2). Therefore, oral

epidemiology uses multidimensional constructs known

as socio-dental indicators or oral health–related quality

of life measures (OHRQoL), which refer to the extent

to which oral disorders disrupt an individual’s normal

functioning and result in major behavior chang (3, 4).

To date, OHRQoL has become an important tool

for assessing the impact of a range of oral and

systemic conditions on an individual’s quality of life

and well-being (5- 10). The outcomes of clinical care,

such as the efficiency of treatment interventions, are

also important (11, 12).

Several measures have been developed that have

the potential to be used this way (4). The Geriatric Oral

Health Assessment Index (GOHAI) is a questionnaire

designed to assess the impact of oral conditions on the

quality of life (QoL) of the elderly population. GOHAI

has also been referred to as the General Oral Health

Assessment Index (13).

The original GOHAI has 12 negatively and

positively worded items assessing three dimensions of

OHRQoL: 1) physical function, representing the

pattern of eating, speech and swallowing; 2) pain or

discomfort, representing the use of medications to

relieve pain or discomfort in the mouth; 3)

psychosocial function, representing the worry or

concern about oral health, dissatisfaction with

appearance, self-consciousness about oral health and

avoidance of social contacts because of oral problems

(13).

GOHAI has also been found to be a remarkable

predictor of self-rated dental appearance in aged people

(14). In comparison with other self-reported measures

of oral health, GOHAI has been found to be sensitive

to dental treatment needs (15, 16). Although GOHAI

has been translated into several languages and tested

for its validity and reliability (1, 2, 16-23), a Persian

version is not yet available. The purpose of this study

was to develop a Persian version of the GOHAI, to

make the obligatory cultural and ethnical adaptation

and to evaluate its reliability, validity and internal

consistency for use among the Persian people.

Methods

English version of the GOHAI: The English

GOHAI has 12 items in three hypothetical dimensions:

physical function, psychosocial function and pain

and/or discomfort. For each of the 12 items, the

participants were asked if they have always, often,

sometimes, seldom or never experienced any of those

problems in the previous 3 months.

The questions were sometimes worded in a

positive manner and sometimes in a negative manner to

force respondents to consider their answer. The

responses were scored on a scale ranging from 1 to 5

(1=never; 2=seldom; 3=sometimes; 4=often;

5=always).

When the data were interred into a database, the

responses were recoded, if necessary, so that responses

indicating good conditions and no problems carried the

highest scores. Thus, the scale score was a sum of

values; a low value indicated an oral health problem. A

summary score (Add-GOHAI) ranging from 12 to 60

was calculated for each subject, with a higher score

indicating better oral health.

The translation process and the pilot study: The

proposal of this study was approved by the Research

Committee and the Ethics Committee of Babol

University of Medical Sciences. The written informed

consent was taken from each participant. The GOHAI

was translated into Persian.

The process involved translating from English to

Persian by two bilingual people whose first language

was Persian and then a backward translation from

Persian to English by two bilingual people whose first

language was English.

Once the translation was complete, comparisons

between the original English, the back-translated

version and the Persian version were drafted and

revised by two professional translators and scrutinized

for changes in sense.

The final Persian version was then tested on a

sample of adults (n=40). The volunteers first answered

the 12 questions from the final Persian version on their

own; then, they were asked the same questions in an

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Caspian J Dent Res - March 2013, 2(1): 8-17

Validation of persian GOHAI version

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interview. The interviewers probed the answers to

ascertain the meaning equivalent to the original and

recoded the volunteers' comments and any difficulty

that they encountered.

The comprehensibility of the translated version

was assessed, and only minor changes were made to

make the questionnaire more understandable. To

evaluate test-retest reliability, the GOHAI was re-

administered after one week.

Main study

Sample size: The sample size calculation was

based on the test-retest reliability, which was measured

by the intraclass correlation (r). To be acceptable, the

questionnaire had to have an r=0.8 and an r≥0.7; thus,

H0: P0=0.7 and H1: P1=0.8. A two-sided test

suggested by Atieh et al, (14) was used. With β=0.2

(80% power) and α=0.05, a sample size of 150 subjects

was required.

Data collection: The final Persian version of the

GOHAI was administered to 150 Persian adults (20–65

years old) attending Ayatollah Rohani Hospital from

September 2009 to February 2010. The data came from

a self-administered questionnaire followed by a clinical

oral examination performed by a single dentist. In

addition to the GOHAI items, the questionnaire

included socio-demographic data such as age, gender,

educational level and employment. The subjects were

also asked about the use of removable prostheses, self-

rated oral and general health and dental treatment

needs.

All oral examinations were performed the same

day the questionnaire was administered, in either a

dental or medical examination room using portable

lamps and disposable instruments. The oral status

examination based on 28 teeth involved recording the

number of missing teeth, DMFT, root DFT, pathologic

tooth mobility and the Oral Hygiene Index-Simplified

(OHI-S).

Data analysis: The analysis of the study was

carried out using STATA V 10 and SPSS 17.0 for

Windows (SPSS 17.0, SPSS Inc. Chicago, IL, USA).

The mean Persian GOHAI scores were calculated for

the demographic variables using the independent t-test

and ANOVA.The GOHAI was computed by adding the

score of the 12 items; the final values ranged from 12

to 60.

The original scores were kept for three items—

―able to swallow comfortably‖, ―able to eat without

discomfort‖ and ―pleased with look of teeth‖—and

reversed for the remaining nine items, such that a

higher score was associated with a more positive oral

health. The test-interview and test-retest reliabilities

were assessed by paired t-test, the Spearman

correlation coefficient and weighted kappa values. A

Bland–Altman plot was also used to describe the

agreement between the two GOHAI scores taken from

the same participants on two separate occasions.

The internal consistency of the GOHAI was

assessed by the standardized Cronbach's alpha (the

reliability coefficient), the alpha if the item was deleted

and the inter-item and inter-table correlation

coefficients.

Concurrent validity was assessed by examining the

relation between the GOHAI scores and the global oral

health rating questions. It was hypothesized that the

subjects reporting functional problems, pain or

discomfort or psychosocial impacts would have a low

GOHAI score and would be more likely to report

dissatisfaction with their oral health, more likely to

report their oral health as fair or poor and more likely

to report a self-perceived need for dental care. The

discriminant validity was tested by comparing the

individuals’ item responses and GOHAI scores with

their objectively evaluated dental condition.

Results

For the test-interview, the mean GOHAI score was

50.37–51.1, (p=0.009), and for the test-retest, the mean

GOHAI score was 51.28–51.05 (p=0.776) (table 1).

The Bland-Altman plot showed a good agreement

between the two GOHAI scores for both the test-

interview and test-retest conditions (figure. 1, 2).

In the main study, 150 individuals with a mean age

of 31.2 (SD: 8.8, range: 20-65 years) completed the

GOHAI questionnaire; the distribution of responses on

the individual GOHAI items is displayed in table 2.

Half of the subjects were 30 years of age or older.

The majority of the participants were females (68.7%).

In terms of education, 43.3% of the subjects reported

having completed high school, and 35.5% had a high

educational level.

The mean GOHAI score was 46.78 (SD=7.85;

range 27–60). In relation to the reliability of the

Persian version of GOHAI (table 3), Cronbach’s α

(0.78) showed a high degree of internal consistency

and homogeneity between items.

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Motallebnejad M, et al.

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Figure 1. Bland-Altman plot (test-interview)

Figure 2. Bland-Altman plot (test-retest)

Table 1. Test-interview & test-retest correlation for the Persian GOHAI items

Item Weighted

kappa

Spearman’s

rank

correlation

coefficient

Weighted

kappa

Spearman’s

rank

correlation

coefficient

Limit the kinds of food 0.783 0.876 0.353 0.445

Trouble biting or chewing 0.829 0.585 0.525 0.709

Able to swallow comfortably 0.868 0.904 0.509 0.571

Unable to speak clearly 0.825 0.866 0.463 0.516

Able to eat without discomfort 0.600 0.620 0.592 0.637

Limit contact with people 0.884 0.954 0.425 0.498

Pleased with look of teeth 0.842 0.827 0.508 0.559

Used medication to relieve pain 0.798 0.872 0.329 0.430

Worried about teeth, gums or dentures 0.888 0.956 0.424 0.519

Self-conscious of teeth, gums or

dentures 0.751 0.775 0.638 0.763

Uncomfortable eating in front of others 0.749 0.865 0.590 0.635

Sensitive to hot, cold or sweet foods 0.958 0.980 0.447 0.552

Total – 0.971 – 0.779

Kappa<0.40 (poor agreement), 0.41–0.60 (moderate agreement), 0.61–0.80 (good agreement),>0.80 (very good agreement)

There was no significant relationship between

mean GOHAI score and the subject’s age, gender, use

of removable partial dentures or Oral Hygiene Index–

Simplified (OHI-S), although the subjects with a good

OHI-S had a higher GOHAI score than those who had

a fair or poor OHI-S. The individuals with a low level

of education had lower GOHAI scores compared with

the well-educated respondents (table 4). In relation to

the concurrent validity (table 4), the subjects with a

higher mean GOHAI score were more satisfied with

their oral and general health, whereas, low GOHAI

scores were associated with self-perceived fair or poor

oral health, self-perceived fair or poor general health, a

low level of satisfaction with oral health and with the

self-perception of dental needs. In relation to the

discriminant validity (table 5), the respondents with

higher GOHAI scores were associated with a lower

number of carious and missing teeth (figure. 3), a

better OHI-S score and fewer pathologically mobile

teeth.

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Table 2. Distribution of responses on individual GOHAI items (%)

GOHAI items

1

never

2

Seldom

3

sometime

s

4

often

5

always

Limit the kinds of food 57.3 12.0 25.3 4.7 0.7

Trouble biting or chewing 44.0 12.0 27.3 11.3 5.3

Able to swallow comfortably 16.0 2.7 10.0 24.0 47.3

Unable to speak clearly 76.0 9.3 6.0 4.7 4.0

Able to eat without discomfort 10.0 8.7 12.0 32.7 36.7

Limit contact with people 72.0 11.3 10.7 4.7 1.3

Pleased with look of teeth 15.3 22.0 22.0 21.3 19.3

Used medication to relieve pain 66.0 12.0 12.7 7.3 2.0

Worried about teeth, gums or dentures 30.0 14.7 22.0 20.7 12.7

Self-conscious of teeth, gums or

dentures

51.3 14.0 22.0 11.3 1.3

Uncomfortable eating in front of others 56.7 17.3 16.0 6.7 3.3

Sensitive to hot, cold or sweet foods 24.0 18.0 32.0 18.7 7.3

Table 3. Reliability analysis using Cronbach’s alpha

Item

Corrected item–

total correlation

Cronbach’s alpha if

item deleted

Limit the kinds of food 0.550 0.753

Trouble biting or chewing 0.583 0.746

Able to swallow comfortably 0.041 0.810

Unable to speak clearly 0.372 0.769

Able to eat without discomfort 0.273 0.781

Limit contact with people 0.236 0.780

Pleased with look of teeth 0.388 0.768

Used medication to relieve pain 0.478 0.759

Worried about teeth, gums or entures 0.596 0.743

Self-conscious of teeth, gums or entures 0.546 0.752

Uncomfortable eating in front of others 0.651 0.741

Sensitive to hot, cold or sweet foods 0.455 0.761

Cronbach’s alpha= 0.780, Standardized Cronbach’s alpha= 0.789

Figure 3. Correlation between GOHAI scores and DMFT

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Motallebnejad M, et al.

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Table 4. Concurrent validity of GOHAI scores and certain groups of questions

Variable

(standard deviation)

GOHAI

Mean±SD

Test

Self-rating of oral health

ANOVA

P value=0.090

Good : n=36 49.11±8.91

Fair: n=96 46.32±7.51

Poor: n=17 44.59±6.85

Self-rating of general health

ANOVA

P value=0.047

Good : n=74 48.01±8.48

Fair: n=74 45.81±6.98

Poor : n=21 37.00±2.83

Perception of dental care needs T-test

P value=0.001 Yes : n=129 45.97±7.80

No: n=20 52.10±6.28

Age T-test

P value=0.339 18–30 years: n=85 47.32±7.57

31–65 years: n=65 46.08±8.21

Gender T-test

P value=0.417 Male n=47 47.55±7.87

Female n=103 46.42±7.86

Educational level

ANOVA

P value=0.002

Primary school n=32 44.31±8.30

High school n=65 45.40±7.13

Associate’s degree n =17 48.41±8.92

Bachelor’s degree n=36 50.69±6.79

Wears removable partial denture T-test

P value=0.587 Yes n=3 44.33±7.09

No n=147 46.83±7.88

Oral Hygiene Index–Simplified (OHI-S)

ANOVA

P value=0.498

Good n=83 47.57±7.70

Fair n=49 45.98±7.40

Poor n=15 46.27±9.18

Table 5. Discriminant validity

Mean

Range

Pearson's correlation

coefficient with GOHAI

score

P value

Age 31.23 18–57 –0.064 0.439

Missing Teeth 2.80 0–23 –0.318 0.000

DMFT 8.06 0–24 –0.354 0.000 Root DFT 0.04 0–2 –0.01 0.906

Simplified Oral Hygiene Index

(OHI-S)

1.373

0–4.8

–0.157

0.057

Teeth with pathologic mobility

(>2 mm and/or can be

displaced in a vertical direction)

0.04

0–2

–0.066

0.421

GOHAI

46.78

27.00–

60.00

–

–

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Validation of persian GOHAI version

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Discussion

The GOHAI was originally presented and

evaluated for assessing oral health–related quality of

life in middle-aged and well-educated Americans, but

subsequent studies showed that it could also be

successfully used in less-educated young people (2).

Cultural and language differences, which can even

occur in one country, make validity assessment more

complicated.

People with different cultural backgrounds may

respond differently to GOHAI items. For instance,

being edentulous (missing teeth) may have different

levels of importance in various cultures. As a result,

people's quality of life given the same oral conditions

may be evaluated differently.

Therefore, it is important that the GOHAI be

tested in diverse populations in terms of culture,

language and geography. In this study, the first step

consisted of using a standardized translation process.

Translation and back-translation were performed to

ensure the accuracy and interpretability of the

questions, and this led to the creation of a Persian

version with pleasing psychometric properties. The

assessment of certain social and demographic

characteristics, including age and gender, did not

indicate significant differences in the mean GOHAI

scores for these parameters.

The concurrent validity of the Persian version of

the GOHAI was tested and confirmed; there was a

meaningful relationship between individuals' self-

report of general health and dental care needs with

GOHAI scores.

In addition, people with a good self-impression of

their oral health received higher mean GOHAI scores

compared with those with moderate to poor self-

impressions, and all of these cases display high

concurrent validity with the Persian version of the

GOHAI.

The clinical indicators studied in the discriminant

validity assessment had been used in other studies as

well (2, 19, 21 and 24).

Because the GOHAI has not been specifically

proposed as a predictor of clinical indices, it should be

used as a complement to clinical and objective

assessments. Some articles have shown reasonable

correlation between the GOHAI and clinical

observations (2, 19, 24), whereas others have

mentioned the weak correlation between them (25). In

the present study, the correlation was significant

between the clinical indicators such as DMFT and the

number of missing teeth.

For loose teeth, a weak relationship with the

GOHAI score was observed. However, in the study by

Atieh et al, who provided the Arabic version of the

GOHAI, the clinical index revealed the strongest

relationship with the GOHAI score (21); the cause of

this difference could be potentially explained by the

mean age group studied, which was 71.20 (age range:

60–90) years in the Arab studies and 31.2 (age range:

18–65) years in our study.

All assessment instruments should possess the

quality of repeatability at different times. In this case,

the same results at two different time points for a

patient would indicate that the patient’s situation had

not changed. The findings demonstrated that the

questions on the Persian version of the GOHAI have

good internal consistency (Cronbach's alpha

coefficient=0.78). This value did not become

significantly larger by eliminating any of the questions,

except question 3 (ability to swallow comfortably),

which showed less internal consistency, suggesting

poor compatibility with other GOHAI questions. The

Cronbach's alpha coefficient would increase if question

3 was deleted.

The question is primarily designed to evaluate the

people with dry mouth problems. Dry mouth is much

more common in the elderly, and thus, the incidence of

swallowing difficulties is more prevalent in middle-

aged people than in younger people (2). It would

probably be better if the GOHAI scoring did not

include this question or if the response was fully

reversed.

The result of the test-retest was acceptable in this

study, and the weighted kappa values were satisfactory

for the GOHAI questions. Only two questions

(numbers 1 and 8) did not have desirable weighted

kappa values. This was a problem for questions 3 and 5

in the French version and for questions 4 and 10 in the

Chinese version of the GOHAI, illustrating that these

questions were not easily understood in these

languages (2, 17).

A Bland-Altman plot indicated an acceptable

result, and the 95% of differences in the questions,

both for the test-interview and the test–retest cases,

were within the limits of agreement.

As conclusion, the Persian version of the GOHAI

exhibited acceptable reliability and validity. This

instrument can be applied to evaluate OHRQoL in

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Caspian J Dent Res -March 2013; 2(1): 8-17

Motallebnejad M, et al.

16

cross-sectional and longitudinal studies of different age

groups.

This version may be better tested for different oral

and systemic conditions and disorders to evaluate the

validity in future studies.

Acknowledgments

We sincerely thank the UCLA for providing the

original version and scoring system of GOHAI. Special

appreciation to Dr. Jenabian N for her critical advice in

translating the questionnaire.

Funding: This project was approved and financially

supported by the Vice-Chancellery for Research &

Technology of Babol University of Medical Sciences

Conflict of interest: There was no conflict of interest.

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